=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730660259
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CALEB STUART CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2018
-----------------------------------------------------
Last Update Date | 03/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 J CLYDE MORRIS BLVD
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-594-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12120 LYNDELL PLANTATION DR
-----------------------------------------------------
City | PANAMA CITY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32407-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-284-7306
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 0024177406
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | RN9429866
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------